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WORKERS'COMPENSATION DEC�ARATION II
� reby affirm that 1 hava a certificote of consenf ro self APPLIC�TION FOR BUILDtNG PERMtT � LS
•e,or a certificate of Workers'Compenstion Insurance,or . p
rtified topy thereof(Sec.3BD0,tab^`C,,��,�-,x• COUNTY OP LOS ANGELES � BUILOING AND SAFETY �'!
y Na.'b�Compony D�.G �
Certifiad copy i:hereby furnished. FOR APPLICANT TO PILL IN AO RESS c �'✓ �.
�� Certifiad copy is filed with th unty building inspeo- BUILDitaG ,� � � ������,t�,�
�'� tion deparfineM. , ADDRESS � ' � L LITV ���C�'�`^'���
� �7 NEAREST {� �
� 7—� APPIic nt �� Cltr iP CROS55T. G� i�-�` �
CERT�FiCATE OF EXEMP FRONi WDRKERS' NO.OF BLDGS. ASSESSOR
COMPENSATION INSURANCE SIZE OF LOT NOW ON LOT M.4P BOOK PAGE PARCEL
section need not be compleled if Ihe permif is for one USE ZONE MAP ?�
�ed dollars($100)or tess.� � TRA�T BLOCK LOT NO. NO. �_� y
7E�. � SPECIAL y
fy that in ihe performance of ihe work far which this OWNER � � L NO. CONDITIONS
1 is issued,I sholl nol em lo an erson in an manner / `, � DISTRICT GROUP 7VPE iIRE P SSED BY O
P Y Y P Y ADDRE55 1p S N. �iV GV L D � �i�I � CIXJST. ZONE �
fo become su6jecl fo the Wo ers'Compensation laws. O
CITY Z�P STATISTICAL C1A55�FlG4TION �APT. CONDp. V
APP��CO ARCHITECi OR TEL N,1
E TO APPLICANT: If, of r ak ng lhis Certificote of ENGINEER NO. ClASS N0. DWELL.UNITS a
,tion, you should become ubjed to fhe Workers' Z
�nsotion provisions of Ihe Labor Code,you m�at Tonh- qppRE55 SEWER MAP
omply with such provisions or this permif shall be /�� .
�d revoked. ��� gK. pG, VALIDATION
CONTRACTOR`(> O � d
�LICENSED CONTRACTORS DECLARATION . uC
y affirm ihat I om litensed�nder provisions of Chapter 9 ADDRE55 � Z� � VAlUAT10N
ancing wi�h Sec�ion 7000J of Division 3 of the Business and � (� �, A
on5 Code,and my license is in fuil force and effed./ CiTv C7vvl,'l'ti, CiA55 l: '�5 S .
SQ.fT. NO.OP NO.OF CHECK
s r_"�� SIZE STORIES �� FAMIl1E5 ONE
N� u�.ciaz5 �,, !�
� � +J NEW $ ((/D� �� G 9��f a .
f f lllwri.Dale `� �ESCRIR�ION OF WONK �J � *� n
r/ ,�r� ,.� p p AOD � . • • •�r�v
xemp�from e licens�ng requlremen�s as 1 am a � l. �'+`• Wc� +��+ pl '
censed orchiiecf or a registered professional engineer AtTER ❑ DA E` `-' ���Q` ! � �, �t��
is cting in my professional copocity (Section 7051, � � REPAIR � �
�siness ond Professions Code. .
) USE OF 4 DEMOL � F�NAI r •" � O��C�= �
E%IS71NG BLDG. 6y
eg.No. J,�Q`'�'� APPLICANT 7EL.�..� /� � �, S% .
OWNER-BUILDER DEC ARAtION ��M ND. `�1C� �j�- �rp(� ����'],��
affirm that I am exempt fro ihe Conirocror's Litensa . P� '" f c}c,f/ �, �
the following reason(Section�031.5, Business and A�RE55 - � � ��;
ns Code: v iaEN� �
' B ILDING d� •r��,4�
as owner of ihe property, or my emplayees with A RE55 .�( �,'3-8'�
' +ges as Iheir sole compensotion,will do the work and , / ! • •Q�.�'C c=�.
�structure is not intended ar offered for sale�Section �« ��TY
74,Bosiness and Professions Code. � MOV G 7E1. Q Fj,�1�.+��
�s owner of ihe property,am e�clusively coniracting COM QOR n10. �Q.(il�l�"r
h licensed contracrors to construci the projeU($eo- ADDRE55
i 7044,8usiness and Professions Cade). � � .
REQUIRE TOTAL SETBACK FROM EXIST.
CONSTRUCTION IENDING AGENCY SET BACK YARD HWY PROP.LWE WIDTH
��fflrm that there is o mns�ruUion lending agency for vRaNi
�mance oi�he work for which this permit is issued P.�_ �
�,Civ.C.). SIDE.� .
P.l.'
lome / `
�1 G A
ddress P.C.Fee E � r V Permit Fee ✓ �
ot I have revd this appliwtion and state that ihe - issuanre Pee V�^ �
�ion is mnecf.I agree ro comply with all Coumy Invesugatian Fee � J 3 tl �
a d State laws reloting�o building construction, Toml Fee �/ r
o thoriz esentaiives of this Counry to en�er f
ba+e-men' d properry far inzpect� n purposes. �_, - � �
�, 7 .SEE REVERSE FOR EXPLANATORY LANGUAGE // /
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